Inquest into the death of John FLAMISH

65y · Male·combined effects of smoke inhalation, burns and ischaemic heart disease

John Flamish, 65, died on 5 June 2017 from smoke inhalation, burns and ischaemic heart disease following a deliberately lit fire in the carpark of public housing at 22-24 Early Street, Parramatta. The fire was set in a parked Mercedes belonging to resident Sidholm Nakhla. A significant contributing factor was that the fire door separating the carpark from the residential stairwell was propped open with a brick, allowing smoke to ventilate into the building. This practice had been ongoing for years prior to the fire. The coroner found smoke entered the stairwell, trapped residents upstairs including Ms Ludkin and Mr Toufan who had to be evacuated by ladder. The specific actions that could have prevented this tragedy include: proper closure and monitoring of the fire door, resident education about fire safety, and agency oversight of fire safety measures in public housing. While the person(s) responsible for the arson remain unknown despite extensive police investigation, the preventability centres on the maintenance of critical fire safety infrastructure.